New strategies for managing drug spend: RA, Cancer, Hep C
Health plans and pharmacy benefits managers (PBMs) continue to use tried-and-true tools—formulary management, benefit design, prior authorization, step therapy and quantity limits—to manage pharmacy costs. But the proliferation of specialty drugs has prompted new techniques for keeping costs in tow.
With inflammatory diseases such as rheumatoid arthritis; cancer; and hepatitis C as three of the four top specialty drivers of 2015, according to Express Scripts’ “Drug Trend Report,” it’s critical to find innovative management strategies. The three conditions, along with multiple sclerosis, account for 65.4% of total specialty spend, which comprises 17.8% of overall drug costs.
Tried-and-true methods need a makeover
“Standard pharmacy management tools don’t work for specialty in terms of cost and access,” says Mark Lelinski, CEO, Pinscriptive, a healthcare analytics company. “… The bottom line is that even when payers dip into their utilization management arsenal, nothing works well enough to truly change the unsustainable, specialty drug trend line.”
Biosimilars and more competition are only partial solutions because they only impact competing drug prices by 10% to 30% at the most, he adds. They also lack direct substitution as is available within an already 80% to 90% generic, nonspecialty market.
Instead, Lelinski recommends precision medicine—targeting the right person with the right drug, delivering the best value-based decision for patients and payers both in terms of cost and health outcomes—and advanced analytics because “you can’t afford a misstep.”